Contributors The analyses were undertaken by LM and GM with AL. All authors contributed to the interpretation of the results and the conceptualisation
of the paper. All drafts were written by KH and commented on by all authors.

Abstract

Background Women now outlive men throughout the globe, a mortality advantage that is very established in developed European countries.
Debate continues about the causes of the gender gap, although smoking is known to have been a major contributor to the difference
in the past.

Objectives To compare the magnitude of the gender gap in all-cause mortality in 30 European countries and assess the contribution of
smoking-related and alcohol-related deaths.

Methods Data on all-cause mortality, smoking-related mortality and alcohol-related mortality for 30 European countries were extracted
from the World Health Organization Health for All database for the year closest to 2005. Rates were standardised by the direct
method using the European population standard and were for all age groups. The proportion of the gender gap in all-cause mortality
attributable to smoking-related and alcohol-related deaths was then calculated.

Results There was considerable variation in the magnitude of the male ‘excess’ of all-cause mortality across Europe, ranging from
188 per 100 000 per year in Iceland to 942 per 100 000 per year in Ukraine. Smoking-related deaths accounted for around 40%
to 60% of the gender gap, while alcohol-related mortality typically accounted for 20% to 30% of the gender gap in Eastern
Europe and 10% to 20% elsewhere in Europe.

Conclusions Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as
an explanation for this difference is often overshadowed by presumptions about other explanations. Changes in smoking patterns
by gender suggest that the gender gap in mortality will diminish in the coming decades.

Introduction

Since the late 1990s there has been evidence that women now outlive men in all countries of the world.1 Historical records show that in Sweden, Denmark, Italy, The Netherlands, England and Wales, the life expectancy of women
has exceeded that of men since the mid to late 18th century, and there has been speculation about the causes of gender differences
since that time.2 Different explanations have been postulated for this gender gap, including biological factors. However, there is considerable
variability, and sometimes rapid change,3 in the magnitude of the female mortality advantage over time and in different countries, a variability that poses challenges
for simple biological explanations for the gender gap. Earlier research suggested that health behaviours, and particularly
men's higher prevalence of smoking, were a major cause of gender differences in the US.4 Here, we use contemporary mortality data for 30 European countries to examine the extent to which men's higher mortality
can be explained by smoking-related and alcohol-related deaths.

All death rates were standardised by the direct method using the European population standard and were for all age groups.
Data were used for the year closest to 2005 (range 2003/2004 to 2006). The proportion of the gender gap in all-cause mortality
that was smoking-related and alcohol-related was calculated for each country as the gender gap for each cause divided by the
gender gap for all causes.

Results

Although all-cause death rates are higher for men than for women in all countries, there continues to be considerable variation
in the extent of the gender difference in contemporary Europe. The gender gap in all-cause death rates varied from 188 (per
100 000 per year) ‘excess’ deaths among men in Iceland to 942 in Ukraine (see table 1). The gender gap showed some geographical patterning such that all of the countries with a gender gap in excess of 400 per
100 000 per year were located in Eastern Europe. Three Northern European countries (Iceland, UK and Sweden) and two Mediterranean
countries (Greece and Cyprus) had a gender mortality gap of 230 per 100 000 per year or less. Outside the former Soviet block,
Belgium (323 per 100 000 per year), Spain (332), France (336), Finland (362) and Portugal (367) had the highest gender gaps
in all-cause mortality.

The proportion of the gender gap in mortality related to alcohol and smoking ordered by the all-cause mortality gender gap
(2003–2005)

There was a fivefold difference between the countries with the lowest (Iceland: 97 per 100 000) and highest (Ukraine: 495
per 100 000) gender gap in smoking-related deaths. Despite this variation, smoking-related deaths accounted for between 40%
and 60% of the gender gap in all countries except Denmark (39%), Portugal (38%) and France (38%), where smoking-related deaths
accounted for a slightly lower proportion, and Malta (74%), where smoking-related deaths accounted for a higher proportion
(see table 1). Smoking-related mortality was high in men and women in Eastern European countries where the absolute difference in the
gap was also high.

There was an eightfold difference between the countries with the lowest (Iceland: 29 per 100 000) and highest (Lithuania:
253 per 100 000) gender gap in alcohol-related deaths. As expected,6 alcohol-related deaths were particularly high in men in the Eastern European countries (where the rates for women were also
high in comparison with other European countries). Alcohol-related deaths also accounted for a substantial proportion of the
gender gap in all-cause mortality (typically for around 20%), although the proportion tended to be higher in Eastern Europe.
Despite large gender differences in alcohol consumption across societies and the huge variation in alcohol-related deaths
across Europe, the contribution of smoking-related mortality to the gender gap in all-cause mortality was greater than that
for alcohol-related mortality in all countries examined (see table 1).

Discussion

Mortality is higher in men than women across Europe, but there is considerable variation in the magnitude of this gap (from
an ‘excess’ of 188 deaths per 100 000 per year in Iceland to 942 per 100 000 per year in Ukraine). Smoking-related deaths
accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for around 20% of the
gender gap. The range in the contribution of smoking-related deaths reflects gender differences in the uptake of smoking by
gender in earlier decades.7

The strengths of this analysis are the use of best available data from the WHO (who endeavour to quality assure the data)
and the inclusion of most large European countries (with the exception of Turkey). There are, however, also some limitations
to consider. First, alcohol and tobacco use contribute to some shared causes of mortality and morbidity and so any division
into alcohol-related and smoking-related causes will underestimate the scope of influence of each on mortality. For example,
liver cancer has been linked with excessive alcohol consumption for some time, but more recently smoking has been also shown
to be associated with this malignancy. Similarly, tobacco and alcohol consumption contribute to the development of cancers
of the aerodigestive tract.8 This is the rationale behind ‘Peto's method’ of benchmarking smoking-related deaths within each country against lung cancer
deaths,9 as one method of estimating smoking related deaths. The WHO's definitions acknowledge that smoking and alcohol contribute
to some causes of death (oesophageal and throat cancer) but not others. Unfortunately, the cause-specific data required for
applying any alternative definitions were not available from the WHO-HFA database and so we were constrained by the WHO's
definitions. A second limitation is the potential for differential coding practices to bias the cause-specific death rates
between countries despite the use of the International Classification of Diseases system. Third, the WHO-HFA database only
provides these data by gender for all ages together so we were unable to examine relationships in specific age groups.

It is no surprise that two of the most important health behaviours, smoking and hazardous drinking continue to account for
substantial proportions of the gender gap in mortality because health behaviours have long been a powerful way of portraying
gendered identities.10–15 For example, it has been suggested that cultural portrayals of drinking keep shifting to maintain a gendered distinction
in drinking behaviours, so that as men and women both modify their drinking behaviours, considerable effort is devoted to
constructing men's drinking in different ways to women's drinking.16 The balance of the contribution of smoking-related and alcohol-related deaths and the degree of consistency of the pattern
across Europe is perhaps more of a surprise given the complexity of associations between gender, smoking and drinking over
the preceding decades, the long lag time between exposure to smoking and disease (estimated to be between 20 and 35 years
for lung cancer,17 and 30 to 40 years for other cancers such as colorectal cancer18), the considerable variation in the magnitude of the gender gap in all-cause mortality and the different stages in the smoking
epidemic that countries of Northern, Western, Southern and Eastern Europe have reached. What is clear is that smoking accounts
for a substantial part of the gender difference in mortality in contemporary Europe. The importance of health behaviours (and
in particular smoking) in accounting for a large proportion of the gender gap in mortality is often lost in discussion of
gender and health. For example, it is often suggested that other factors (such as differences in consultation for illness)
account for much of this difference (see for example White and Witty19) despite a paucity of robust evidence.20

The continuing uptake of smoking among a significant minority of young people, and increases in detrimental patterns of alcohol
consumption, point to the ongoing need for public health measures to reduce health-damaging behaviours. However, the continuing
links between smoking and drinking and cultural constructions of gender demonstrate that action to reduce smoking and harmful
drinking cannot be tackled at an individualistic level alone. These behaviours are culturally bound and these cultural constructions
of behaviours are partially shaped by and exploited by the alcohol and tobacco industries (see for example Amos and Haglund,
and Toll and Ling1121), in addition to people's structural opportunities and constraints.22

Profound changes in the population level of smoking and in the magnitude of the gender gap in smoking should contribute to
smaller gender differences in mortality in coming decades, beginning first in countries in Western and Northern Europe that
reached the fourth stage of the tobacco epidemic first.7 However, the extent to which this is realised will depend on the ways in which other health risk behaviours are patterned
by gender.

What this paper adds

This study uses contemporary data to examine the contribution of smoking-related and alcohol-related mortality to the gender
gap in all-cause mortality in 30 European countries.

Despite large variation in the magnitude of the gender gap in all-cause mortality in these countries in 2005 and the fact
that the countries are at different stages of the smoking epidemic, smoking-related deaths accounted for a large proportion
of the gender gap in all countries examined (typically 40% to 60%).

It may still be several decades before profound changes in gender differences in smoking in some of these countries are reflected
in a smaller contribution of smoking-related deaths to a reduced gender gap in mortality.